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Showing posts with label nail. Show all posts
Showing posts with label nail. Show all posts

Koilonychia and its causes

Koilonychia is the spoon-shaped deformity of the nail ,it is usually found in chronic iron deficiency anaemia.
Koilonychia develops due to the retarded growth of the nail plate. Koilos' means hollow and onych' means nail.
How will you examine for koilonychia ?
To examine for koilonychias first keep the patients finger at your eye level and look tangentially, you can observe as well as palpate the nail plate for spooning or flattening
What are the stages of koilonychia ?
There are three stages of koilonychia
First stage is characterised by brittle and rough nail
Second stage is charecterised by flattening of nail without longitudinal ridges and the nail is flat
Third stage the nail is spoon shaped and is concave.
What are the causes of koilonychia?
Causes of koilonychias are the following

  • Iron deficiency anaemia
  • Haemochromatosis
  • Raynaud's syndrome
  • Porphyria
  • Occupational

              Motor mechanics
              Rickshaw pullers

  • Ischaemic heart disease
  • Syphilis
  • Inherited—autosomal dominant.

What are the causes of clubbing?

Cardiovascular cause of clubbing 
  • Infective endocarditis
  • Cyanotic CHD
  • Myxoma of atria
  • Aneurism of major vessels such as aorta and  subclavian artery
Gastrointestinal causes of clubbing 
  • Malabsorption
  • IBD - Crohn's, ulcerative colitis
  • Cirrhosis of liver particularly biliary cirrhosis
Respiratory causes of clubbing
  • Broochiectasis.
  • Lung abscess.
  • Bronchogenic carcinoma.
  • Empyma thoracis.
  • Fibrosing alveolitis.
  • Pleural mesothelioma.
  • Pulmonary arteriovenous fistula.
  • Cystic fibrosis.
In pulmonary tuberculosis clubbing denotes
  • Post tuberculous bronchiectasis
  • Diffuse B/L lung fibrosis
  • Empyema
Others  causes of clubbing 
  • Congenital 
  • Thyrotoxicosis 
  • Acromegaly
  • Unidigital clubbing is seen in - sarcoidosis, trauma, gout.
  • Pachydermoperiostosis
  • Thyroid acropachy
What are the different types of clubbing?
Drum stick type of clubbing  is seen in
  • Congenital cyanotic heart diseases, e.g. Fallot's tetralogy.
  • Bronchiectasis.
Parrot-beak type of clubbing : Commonly seen in bronchogenic carcinoma.
What are the  causes of painful clubbing ?
  • Bronchogenic carcinoma.
  • SBE.
What are the causes of unilateral clubbing ?
  • Presubclavian coarctation of aorta (left sided clubbing).
  • Bronchogenic carcinoma.
  • Cervical rib.
  • Aneurysm of subclavian artery.
  • Ervthromelalgia.
  • Arteriovenous fistula of brachial vessels.
What are the causes of unidigital clubbing?
  • Hereditary (if bilateral).
  • Local trauma.
  • Rarely from median nerve injury' or deposition of tophi (gout).
  • Sarcoidosis.
Causes of clubbing limited to upper extremity ?
Chronic obstructive phlebitis of upper extremity as a result of chronic I.V drug addiction (eg. heroin).
Causes of clubbing limited to lower extremity ?
In infected abdominal aortic aneurysm : sometimes in PDA with reversal of shunt.
What is the cause of acute clubbing ?
Development of clubbing within 10 to 14 days of onset of illness.This is seen in lung abcess
What are the causes of pseudoclubbing?
Psuedoclubbing is seen in conditions associated with subperiosteal bone resorption of terminal phalanges. Here there is absence of soft tissue proliferation and increased curvature of nails and is seen in.
  • Scleroderma.
  • Acromegaly.
  • Hyperparathyroidism.
  • Leprosy.

How will you examine for clubbing ?

First step  for examination of clubbing is 
Bring the patient's lingers at examiners eye level and look tangentially.You should observe the onychodermal angle. If the angle is 180° or more, it is said that clubbing is present.
Second step for examination of clubbing 
Very early clubbing can be detected by increase in fluctuation of the nail-bed it is due to softening of the nail-bed. To elicit 'fluctuation', the patient's finger (index finger) is placed on the pulp of examiner's two thumbs and held in this position by gentle pressure with the tips of examiner’s middle fingers applied on the patient's proximal interphalangeal joint. The patient's finger is now palpated over the base of the nail by the tips of examiner's index fingers. There is always some amount of fluctuation is present in normal fingers. Clubbing is said to be present when fluctuation is obvious here the palpation of the nail-bed may give the impression that the nail is floating on its bed.
For detection of clubbing, you should first examine the onychodermal angle and then the fluctuation.
What is the most reliable  early sign of clubbing ?
Loss of normal onychodermal angle is one of the earliest sign is of clubbing  increased fluctuation of the nail-bed although occur early is not always reliable.
Which fingers are affected first in clubbing ?
Usually the index finger is affected first in clubbing
What are the points to note when clubbing is detected?
  • Unilateral or bilateral.
  • Painful or not.
  • Presence or absence of central cyanosis.
  • Presence or absence of dyspnoea.
  • The degree of clubbing.
What are the grades of clubbing?
Grade 1-Increased fluctuation of nailbed which lead to increased looseness of base of nail
Grade 2-Obliteration of nailbed angle more than or equal to 180 . It can be demonstrated by keeping the finger in profile view this is called profilesign
Grade 3-Parrot beaking—Biconvexity of nail
Grade 4-Drumstick nail-Bulbous enlargement of distal portion of fingers and toes
Grade 5-Hypertrophic osteoarthropathy-with the above mentioned features plus 
  • Thickening of periosteum
  • Distal arthropathy
  • Periosteal tenderness and heaviness of hands

Clubbing and its pathogenesis

Clubbing is the bulbous swelling of the terminal part of the fingers and the toes with an increase in the  soft tissue mass, and increased anteroposterior as well as transverse diameter of the nails due to proliferation of subungual connective tissue.
Normal angle between the skin and the nail bed is 160 degree. It is also called as lovibond angle Obliteration of this angle is an early sign of clubbing.There is also increase in the  soft tissue of distal part of the fingers and toes.This is manifested as biconvexity of nail and the bulbous distal portion of fingers.
In normal nails when the thumb nails are placed in opposion There is a lozenge shaped gap .In clubbing this gap is obliterated called as Schamroth's window test or sign.
What is the basic mechanism of clubbing?
Arterial hypoxemia and neurohumeral stimulus produces hypervascularity and opening up of anastamotic channels in the nail bed which lead to overgrowth of soft tissue.This is the basic mechanism of clubbing
Why the pulp tissue is increased in clubbing ?
Pulp tissue is increased due to
  • Proliferation of subungual connective tissue.
  • Interstitial oedema.
  • Dilatation of arterioles and capillaries.
What is the pathogenesis of clubbing?
There are several theories to explain clubbing
Hereditary' predisposition - an autosomal gene of variable penetrance has been detected.
Vasodilators such as prostaglandins, bradykinins, 5-HT may be responsible for the development of clubbing. In bronchogenic carcinoma, vasodilator substances which are normally detoxified by lungs enters unaltered into systemic circulation
There is trapping of megakaryocytes and platelet clumps with local release of platelet-derived growth factor (PDGF) and other cytokines which increase the capillary permeability (latest and most acceptable theory). Arterial hypoxemia and neurohumeral stimulus produces hypervascularity and opening up of anastamotic channels in the nail bed which lead to overgrowth of soft tissue.
Possible mechanism of clubbing
The different hypothesis are
  • Anoxia- It is the most important theory which leads to opening up of deep arteriovenous fistula of the terminal phalanges. Fallot's tetralogy is an example
  • Toxic - Example is SBE.
  • Reflex theory- Vagotomy often improves the clubbing in bronchogenic carcinoma.
  • Metabolic causes - Example is thyrotoxicosis.
  • Humoral theory- Increased growth hormone, parathormone, bradykinin. eg. acromegaly. Pressure changes between the radial and digital arteries.
  • Reduced ferritin (may escape oxidation in lungs and leads to dilatation of  arteriovenous anastomosis by entering into systemic circulation) may play an important role (recent view).

What are the changes in nail colour?

 The following changes in nail colour is noted in various conditions
Lindsay Nail 
It is characterised by proximal dull white portion and a distal pink or brown portion with a well-demarcated transverse line of separation. Seen in Uraemia
White Nail (Terry Nail)
It is characterised by white color in the nail bed than the nail plate.
Causes of white nail are 
  • Anaemia
  • Hypoalbuminaemia (cirrhosis, nephrosis)
  • Diabetes mellitus
  • CCF
  • Rheumatoid arthritis
  • Malignancy.
Red Nail
Congestive cardiac failure.
Blue Nail
  • Wilson's disease (Copper deposits)
  • Silver deposits.
Black Nail 
  • Peutz-Jeghers syndrome
  • Cushing's syndrome
  • Addison's disease
Yellow Nail Syndrome
It is characterised by yellow finger and toe nails
clubbing and onycholysis.
The other associated features are: Edema of finger, ankle and face 
Infection-sinusitis, bronchitis, bronchiectasis, pleural effusion
Carcinoma of skin, Larynx, endometrium e Lymphoma

Causes of alteration in nail

Causes of alteration of nail are
  • Clubbing
  • Koilonychia
  • Beausline
  • Plummer nail
Beau’s Line are the transverse ridges in the nail plate due to temporary alteration of nail growth rate.
Causes of Beaus line are the following
  • Acute febrile illness
  • Pneumonia
  • Exanthems—Measles, Mumps
  • Myocardial infarction, Pulmonary infarction
  • Childbirth
  • Drug reaction.
Plummer Nail
Onycholysis of the nail (rat bitten nail)
  • Hypothyroidism, hyperthyroidism
  • Raynaud's disease
  • Porphyria
  • Photo-onycholysis—Doxycycline, chlortetracycline and chloramphenicol.

What is the significance of examination of nail ?

As lot of clinical signs are reflected in the nails it is considered as a marker of various systemic diseases
Various abnormalities are seen in nail which include 
1.Change in the shape of nail
Koilonychia is  dry brittle spoon shaped nail ,in the early stages there is flattening of nail. This is seen in iron deficiency anemia.
Plummer's nail
Brittle nail with longitudinal ridges and distal onycholysis seen in hypothyroidism
2.Different lines in nail
Beaus line
Transverse furrow in the nail plate due to temporary arrest of of nail growth this is seen in association with serious systemic disease
Mees lines
White transverse band in nail plate seen in  arsenic poisoning and septicemia.
3.Change in nail colour
Lindsay nail Half half nail
Seen in chronic renal failure
There is proximal dull white portion and distal pink or brown portion with a well demarcated line of
Whitenail or Terry's nail is seen in hypoalbuminemia in cirrhosis and nephrotic syndrome.
Blue nail
Azure lunule-bluish discoloration of lunule of nail seen in Wilson's disease.
Yellow nail syndrome
Comibination of yellow nail, broncheictasis and nephropathy.
Glassy nails are seen in cirhhosis of liver
Discoloration of nail is produced by drugs like busulphan, zidovudine, phenothiazine, antimalarials and antibiotics.
4.Bleeding manifestation
Splinter haemorrhage is linear subungual hemorrhage away from free nail margin it seen in infective endocarditis and trichinosis.In infective endocarditis it is vertical haemorrhage and and in trichinosis it is horizontal
Nail bed infarct observed in  Vasculitis - SLE, PAN.
Nail fold telangiectasia: Periungual telangiectasia, PSS, SLE, dermatomyositis.
Pitting of nail is seen in Psoriasis.

Onychomyosis is the fungal infection of nail
Distortion of nail growth
Nail growth is distorted in ectodermal dysplasia, chondroectodermal dysplasia, and nail-patella syndrome.